Post-Traumatic Stress Disorder

PTSD Research Developments of 2019: Year in Review

Breakthroughs, puzzles, stagnation, and surprises filled 2019.

Posted Feb 04, 2020

Emerson Lima on Unsplash
Source: Emerson Lima on Unsplash

Towards reviewing the status of research of posttraumatic stress disorder (PTSD) in 2019, I have picked seven studies that represent different areas of importance. I believe that there are only two questions in medical research worth studying: (1) prediction of who is going to develop problems so that the problems may be prevented, and (2) prediction of treatment response in controlled settings. Both can be summarized as the prediction of future behavior; the former in naturalistic settings and the latter in clinical settings. In addition, both are narrowly focused on actually helping people.

In other words, in my view, being interesting is not good enough, which rules out much non-clinical research and most cross-sectional research.  If PTSD research is to be more than an exercise of confirmation bias to support the belief systems of researchers and policy advocates, the wheat needs to be separated from the chaff.  

These are not, in my opinion, the seven best studies. Some are very good and some are flawed studies that I picked to represent an important concept. There is much great research being done, but because the trauma and PTSD research field too often contains non-rigorous studies and questionable misuses of science, one aim of this is to think more critically about the quality of the research.  

1. MDMA-Augmented Psychotherapy for Chronic PTSD

A meta-analysis of clinical trials that used 3,4-Methylenedioxymethamphetamine (MDMA) to augment psychotherapy for the treatment of PTSD found that there exists “moderate-quality evidence” that this intervention is effective, durable, and safe for patients with treatment-resistant PTSD (Bahji et al., 2019).

This could be great news for treatment-resistant sufferers of PTSD  because they have had few good options in the past. The MDMA results, however, sound too good to be true and we need to see this success replicated in bigger trials. Also, application in the real world has some hurdles because MDMA is illegal, no therapists are trained to conduct MDMA-augmented psychotherapy sessions outside of research teams, and insurance does not cover eight-hour-long sessions.

2. What Counts as Trauma?

In a survey of the general population, 35 percent of respondents endorsed non-life-threatening events (e.g., loss of job and breakup of romantic relationships) as their worst life events, despite having been involved in other events that were life-threatening, and then proceeded to endorse PTSD symptoms in relation to the non-life-threatening events (Bardeen and Benfer, 2019).

This study revealed one of the flaws in conducting research with PTSD. It can be difficult to ask respondents in a self-administered questionnaire if they have been involved in a truly life-threatening event, and even if they understand the concept, they will not always stick to the rules of the questionnaire. This has led to many studies in the past to misidentify individuals as having PTSD who do not really have PTSD.

This single study will not put the brakes on non-rigorous research but it does put a number on how frequently PTSD questionnaires may be being completed incorrectly, and ought to serve notice that this is a serious methodological problem in many so-called PTSD surveys.

3. Machine Learning Continues to Search Without Success for Useful Applications

Application of machine learning technique to a large dataset of military personnel concluded that the technique was “encouraging” because the variables of alcohol misuse, male gender, and having been deployed were found to predict probable cases of PTSD (Leightley et al., 2019).

These variables were already known from previous studies, and this does not represent important new knowledge. Machine learning, a subset of artificial intelligence, has been advertised as an improvement over older statistical methods to find patterns, based on the notion that when problems are too complex for human minds, computers can plow through tons of data to find patterns empirically. While machine learning has been useful for some applications (e.g., backgammon and chess), it has routinely failed in health applications.

4. Treatment From the Bottom Up Instead of the Top Down

Adult patients were randomly assigned to a computer-based cognitive-bias modification task (CBM), including four training sessions within one week aimed at turning negative bias into relatively more positive bias. The CBM task did not work better than the sham task because both groups improved about the same (de Kleine et al., 2019).

Traditional psychotherapy treatments work from the top down, meaning that the raw material of psychotherapy sessions is executive function material—autobiographical memories, cognitions, and feelings—but the growing field of CBM has figured out a way to work with unconscious biases from the bottom up. CBM trials have been mostly positive when applied to anxiety, depression, and anger, but this first study with PTSD suggests this technique may not work for PTSD.

5. The Diorama of Neuroscience: The Continuing Failure of Neuroscience to Find Applications

Researchers examined the methylation status of thousands of DNA locations in war veterans with PTSD before and after they received psychotherapy, and found 12 DNA regions that significantly changed by the end of treatment (five regions increased whereas seven regions decreased methylation in subjects whose PTSD improved) (Vinkers et al., 2019).

There are a host of concerns about methylation studies in general (dozens of regions have been implicated; failures of replication; direction of methylation is confusing; the functional meaning of methylation is a black box; and inability to measure methylation in brain tissue). A variety of commentators have been more and more vocal with concerns about neuroscience research in general, and some have argued that it has come to resemble the works of entomologists who collect bug specimens in dioramas—they look interesting but do not have practical implementations.

6. Allowing Patient Choice Improved Outcomes

Researchers took a group of adults with PTSD and randomized them to have choice or no choice in terms of choosing either psychotherapy or medication. Patients who received their preferred treatment had better adherence and better outcomes than those who had no choice (Zoellner et al., 2019).

This was a lovely study—however, in our current business model, there are choices for patients in the abstract but not so much in reality. Psychiatrists who prescribe medication infrequently accept insurance, and most psychotherapists do not offer evidence-based psychotherapy. 

7. How, Exactly, Do Narratives Evolve During Psychotherapy for PTSD?

Researchers rated the recorded psychotherapy narratives of 10- to 18-year-old youths who participated in cognitive behavioral therapy (CBT) for PTSD on four characteristics: mention of internal events, mention of external events, fragmentation, and organized thoughts. To their surprise, they did not find differences in narratives between those whose PTSD diminished and those whose PTSD symptoms did not diminish (Knutsen and Jensen, 2019). 

Conventional thinking has been that more mention of internal events, more mention of external events, more details to prevent fragmentation, and more organization were believed to be better.  While this more-is-more theory may still be true for some people, this study seems to confirm that there are huge individual differences to consider; “less-is-more” is better for many people. It's something valuable for psychotherapists and patients alike to keep in mind.

References

Bahji A, Forsyth A, Groll D, Hawken ER (early online 8/19/2019). Efficacy of 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy for posttraumatic stress disorder: A systematic review and meta-analysis. Progress in Neuropsychopharmacology & Biological Psychiatry 96 (2020) 109735

Bardeen JR, Benfer N (2019). Methodological considerations for assessing trauma history via self-report. Psychological Trauma: Theory, Research, Practice and Policy. 11(5):505-512, 2019 Jul.

Byrne SP, Harpaz-Rotem I, Tsai J, Southwick SM, Pietrzak RH (2019). Latent typologies of DSM-5 PTSD symptoms in U.S. military veterans. Psychiatry Research. 273:266-273.

de Kleine RA, Woud ML, Ferentzi H, Hendriks G, Broekman TG, Becker ES, Van Minnen A (2019). Appraisal-based cognitive bias modification in patients with posttraumatic stress disorder: a randomised clinical trial. European Journal Of Psychotraumatology. 2019, Vol. 10, 1625690.

Goddard E, Onwumere J, Meiser-Stedman R, Sutherland E, Smith P (2019).  Relationship between posttraumatic stress symptoms, caregiving response, and parent mental health in youth exposed to single incident trauma.  Journal of Affective Disorders. 251:15-22, 2019 05 15.

Knutsen M, Jensen TK (2019).  Changes in the trauma narratives of youth receiving trauma-focused cognitive behavioral therapy in relation to posttraumatic stress symptoms. Psychotherapy Research. 29(1):99-111.

Leightley D, Williamson V, Darby J, Fear NT (2019). Identifying probable post-traumatic stress disorder: applying supervised machine learning to data from a UK military cohort. Journal of Mental Health. 28(1):34-41, 2019 Feb.

Vinkers CH, Geuze E, van Rooij SJH, Kennis M, Schür RR, Nispeling DM, Smith AK, Nievergelt CM, Uddin M, Rutten BPF, Vermetten E, Boks MP (early online 23 October 2019).  Successful treatment of post-traumatic stress disorder reverses DNA methylation marks. Molecular Psychiatry, doi: 10.1038/s41380-019-0549-3.

Zoellner LA, Roy-Byrne PP, Mavissakalian M, Feeny NC (2019). Doubly Randomized Preference Trial of Prolonged Exposure Versus Sertraline for Treatment of PTSD. American Journal of Psychiatry. 176(4):287-296, 2019 04 01.